1994, 10-18 Permit App: 94010314 Sewer lit 11.
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: /02//6 (IF KNOWN)
,�' ✓.'� PARCEL NUMBER:
CITY: lcp7kC&h e STATE: (,L ZIP CODE: 98010
OWNER NAME: C7&C y `VC C K e ADDRESS: /0 4!6(e /3 t4
CITY: �pi 702q - E-3,50
CL1,! t_ STATE: Gt1/ ZIP CODE: 910.70
PHONE NUMBER: 7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YESNO
(CIRCLE ON )
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES .
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 1a) (tc1 g,mf,(_ EXC ./0on ADDRESS: 102-) I 40r -1+.4004 CA-
CITY
( -
CITY: �noXane STATE: \n4 ZIP CODE: 6/920(2
PHONE NUMBER: ,5d6i - RCN , / 58(c,
STATE CONTRACTORS LICENSE NUMBER: I /V L AN E 0 G t-f4 V V
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
ASLATANRlL 0
-, "-N.(/-
DATE: iCI '-lYW
SPOKANE
COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675